New Billing Requirements for Rural Health Clinics Causing Issues with Adjudication


A new ruling from The Centers for Medicare & Medicaid Services (CMS) requires rural health clinics (RHCs) to report the appropriate Healthcare Common Code Procedure for each billable service received (whether medically necessary, face-to-face, mental health, or qualified preventive health visits with a RHC practitioner), along with the revenue code and other required billing codes.

The ruling is an effort by CMS to improve quality of patient care and increase transparency and tracking. The purpose of the new requirements focus on:

•    Billing: Compliance with national coding standards and requirements.
•    Rural health clinic payment policies: Collecting data on RHC services to better inform policies.
•    Accuracy: touching on RHC claims processing.

The ruling affects all RHCs, including those exempt from electronic reporting, that are submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries. 

The new ruling, however, has come with some stumbling blocks. It was recently announced that the implementation of the new changes has caused issues in adjudicating RHC claims. This would appear to impact all RHCs nationwide regardless of systems being used.

Below is the latest email sent out with information from the National Association of Rural Health Clinics (NARHC). If you are not already subscribed to the NARHC listserv, you can sign up here:

April 12, 2016

To: RHC Community and Friends
From: Bill Finerfrock and Nathan Baugh
Re: Update on RHC claims being held by MACs

Earlier today you should have received an email announcing that CMS was asking all MACs to hold RHC Medicare claims submitted on or after April 1, 2016 due to processing problems. At that time, it was not clear how significant the problem was nor how long it would take CMS (or the FISS contractor) to fix the problem. 

Since this morning’s announcement, we've received an update from CMS staff. The problem is serious and will take some time to fix but it is not quite as major as first feared. According to the technical people who have looked into the problem, it will take approximately 10 days to fix. The earliest date the programmers think they will have a fix in place will be April 21st and the latest they project will be April 25th. 

What does this mean? 

Because Medicare must already hold all claims for 14 days prior to processing, it appears that RHC Medicare claims with a date of service between April 1st and April 9th/10th will not be paid until the fix is completed. This presumes that the programmers are able to fix the problem within the current timeframe. If it takes longer, claims with a DOS after the 10th or so will begin to be affected as well. 
Please know that while NARHC is not happy that this has happened and we have expressed our displeasure with the CMS staff involved with this process, we will continue to push CMS to fix this at the earliest possible date. We will continue to apply pressure to CMS to get this fixed and minimize the cash flow problems this will cause for rural health clinics. 

Once this is resolved, we will express our displeasure in a more official way but for now, we want to have CMS focus their attention on fixing the problem, not responding to multiple inquiries about what happened and why. 

As we receive more information we will pass it along on this listserve.

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